Paul House & Health Cr Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 3800 North California Avenue, Chicago, Illinois 60618
- CMS Provider Number
- 145767
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Paul House & Health Cr Ctr during CMS and state inspections, most recent first.
A resident with hemiplegia, vascular dementia, a stage 3 sacral pressure ulcer, and a heel wound, who was totally dependent for mobility, was left lying on one side for several hours without being repositioned every two hours as required by the care plan and facility policy. The resident’s family member reported the resident had remained on his right side since the morning, while the assigned CNA stated the last repositioning occurred earlier that morning and cited short staffing and the need for assistance to turn the resident. The LPN was unsure when the resident was last turned, and the DON confirmed the expectation for q2h repositioning for this resident, who could not turn independently and was at high risk for skin breakdown.
A resident dependent on staff for ADL care, including transfers and incontinence care, was left waiting for over an hour without assistance, resulting in the resident sitting in urine and experiencing humiliation. The call light was not within reach, and staff cited heavy workload and short staffing as reasons for the delay, despite facility policy requiring prompt care and accessible call lights.
Two residents requiring assistance with hygiene and daily living did not have access to clean towels or washcloths, with staff and residents reporting frequent linen shortages and the use of blankets as substitutes. Staff interviews and observations confirmed that the amount of linen distributed to units was insufficient for the number of residents, and inventory records showed the facility did not have enough towels to meet minimum care standards. The deficiency affected residents with significant medical and care needs, and was linked to inadequate laundry staffing and supply management.
The facility did not ensure an RN was scheduled for at least 8 consecutive hours daily, resulting in days with no RN coverage. During this time, a resident receiving IV antibiotics via a PICC line had these medications administered by LPNs who were not certified to do so independently and were not supervised by an RN. Staff interviews and records confirmed the absence of required RN oversight and non-compliance with facility policy.
Surveyors found that the facility failed to properly label and date food items, monitor refrigerator and freezer temperatures daily, and maintain correct dishwashing sanitizing concentrations. Foods such as tuna salad, cottage cheese, bacon, and salad dressing were found with expired or missing dates, and temperature logs were incomplete or missing. Dishwashing sanitation buckets were not within the required concentration range, and staff acknowledged these lapses could lead to unsafe conditions.
A garbage can near the dry storage room was observed without a lid, emitting a foul odor and attracting small black insects. The Dietary Manager confirmed this has been a persistent problem, with the area described as 'fruit fly central.' Facility policy requires waste to be placed in closable containers, but this was not followed, affecting all 93 residents.
The facility did not complete a comprehensive facility assessment, omitting input from residents, families, and direct care staff, and leaving key sections such as staffing needs, recruitment/retention plans, contingency planning, medical practitioner collaboration, inventory management, health IT, and infection control blank or incomplete. The administrator confirmed these omissions and stated that some sections were believed to be non-mandatory, potentially affecting all 93 residents.
The facility did not ensure proper infection control measures, including failure to place a resident with wounds and a feeding tube on Enhanced Barrier Precautions, inadequate hand hygiene by staff when passing food trays due to lack of accessible hand sanitizer, and improper handling of soiled linen, with some items not bagged before being sent down the laundry chute. These deficiencies were confirmed by staff interviews and direct observation.
Surveyors found that the facility did not ensure regular cleaning of dryer lint traps in the laundry area, resulting in overfilled and bulging lint filters and lint accumulation on the floor. Staff interviews confirmed that scheduled cleaning was missed, despite facility policies and job descriptions requiring this task for safety and cleanliness. This deficiency had the potential to affect all residents in the facility.
A deficiency was identified when black flying insects, specifically fruit flies, were observed in the kitchen near an uncovered, foul-smelling garbage can. The Dietary Manager reported this had been a persistent issue, and pest control service records did not document treatment for fruit flies on several preventive visits. Both the Administrator and Maintenance Director were unaware of the extent of the problem, despite the facility's policy requiring ongoing pest control.
The facility did not provide or document mandatory QAPI training for staff, as required. Leadership confirmed that direct care staff were not trained on QAPI processes and would not know how to submit concerns to the QAPI committee, relying instead on reporting to supervisors. No evidence of QAPI training was found in in-service records or elsewhere, and the facility assessment did not identify a need for such training. This deficiency had the potential to affect all residents in the facility.
Surveyors found that staff had not received compliance and ethics training, as there was no documentation of such in-service education in the facility's records. Leadership confirmed that no further documentation existed, and the facility assessment did not identify a training need in this area. This deficiency could potentially impact all residents in the facility.
The facility did not ensure that care plan meetings were held or that residents and their families participated in developing comprehensive care plans. Several residents, including those with cognitive impairment and one on hospice, were unaware of their care plans and had not attended care plan meetings. Staff confirmed that only certain departments participated in care planning, and documentation of resident or family involvement was lacking.
Three residents requiring oxygen therapy did not receive care according to physician orders and facility policy: one resident did not receive oxygen due to improper humidifier setup, another had unlabeled oxygen tubing that was not changed as required, and a third received oxygen at a higher flow rate than prescribed. Nursing staff confirmed these deficiencies and acknowledged the expectations for proper oxygen administration and equipment management.
A resident with mobility and personal care needs was left waiting for over an hour in soiled conditions because of insufficient staffing, with only one nurse and two CNAs available for 24 residents. Staff confirmed frequent short-staffing, heavy workloads, and the inability to provide timely assistance, as documented by staffing schedules and interviews. Facility policies requiring adequate staffing and prompt response to call lights were not followed, directly affecting resident care and dignity.
Surveyors identified failures in the handling and documentation of controlled medications, including missed shift-change counts, lack of immediate documentation after administration, and improper repackaging of medication for two residents. Additionally, medication refrigerators were found without current temperature logs, and staff personal food items were stored alongside resident medications, all contrary to facility policy.
Several residents with indwelling urinary catheters had their drainage bags uncovered and visible from the hallway, contrary to facility policy requiring privacy bags. Staff interviews confirmed that this practice did not protect resident privacy or dignity, and one resident reported never having a privacy bag during their stay.
The facility did not ensure that call lights were accessible to several residents as required by care plans and policy. One resident could not find the call light, another had the call light on the floor, and a third had the call light out of reach while waiting in urine for over an hour. Staff interviews confirmed that call lights were not always kept within reach and that staffing shortages contributed to delays in care.
A resident's MDS assessment was not transmitted to CMS within the required timeframe. The assessment was completed and signed, but the MDS Coordinator failed to submit it until it was requested by surveyors, resulting in a significant delay beyond the mandated period.
A resident with heart failure and a history of weight loss did not have weights obtained and documented as ordered by the physician, resulting in a 16-day gap between weight measurements. Confusion over the frequency of weight checks and failure to follow facility policy contributed to the deficiency.
Surveyors found that a resident at risk for pressure ulcers was left in a wheelchair without a pressure-relieving cushion, and two residents using low air loss mattresses had improper mattress settings and excessive bedding layers, contrary to facility policy and manufacturer instructions. These residents had significant risk factors for skin breakdown, and staff confirmed that the observed practices did not follow established protocols for pressure ulcer prevention.
Surveyors found that piston syringes and distilled water containers used for G-tube care were not labeled with change or open dates for several residents, and enteral feeding adaptors were left uncontained at the bedside. Staff, including LPNs and the DON, confirmed that facility policy required daily labeling and replacement of these items for infection control, but this was not consistently followed.
A resident prescribed IV Cefazolin for infection prophylaxis did not receive a scheduled morning dose, with no documentation or explanation provided in the EMR. The resident did not refuse the medication, and the LPN confirmed the dose was missed. Facility policy required timely administration of medications, but this was not followed, resulting in a significant medication error.
The facility did not provide or document communication training for staff, resulting in a resident who primarily speaks Chinese relying on a family member to interpret for care needs due to staff's inability to communicate effectively. Review of training records and staff interviews confirmed the absence of communication in-services.
A resident's personal mail containing medications was opened by the DON without the resident's permission after the receptionist suspected it contained pills. The DON placed the medications in the med cart and later informed the resident, who was alert and able to make his needs known. Facility policy and the Ombudsman Program require that mail not be opened without resident consent, a standard acknowledged by both the DON and the administrator.
A resident experienced delays in call light response, leading to a hospital visit for a heart attack. The resident, dependent on care, faced further delays when attempting to transfer to the toilet without assistance due to a malfunctioning call device. The facility's guidelines stress the importance of functioning call lights, but staff failed to ensure timely responses.
A facility failed to provide a functioning call device for a resident requiring assistance, leading to the resident attempting an unsafe transfer. Despite the bathroom call light flashing, it did not signal in the hallway or at the nurses' station. The Maintenance Director did not perform regular checks, relying on staff to report issues. The resident, with conditions like Parkinson's and osteoporosis, requires substantial assistance, highlighting the importance of functioning call devices.
A resident fell and injured herself when an overbed table she was leaning on detached from its base. The incident, witnessed by a CNA and a physical therapy assistant, occurred due to the facility's failure to conduct preventative maintenance on the tables, which were not designed to support weight beyond holding food.
The facility failed to provide adequate pressure ulcer care for four residents, resulting in significant deterioration of their conditions. One resident developed a stage 4 infected sacral wound requiring surgery due to inconsistent treatment and documentation. Another resident's ulcer worsened from stage 3 to stage 4 due to improper mattress settings and lack of repositioning. Additional deficiencies included incorrect wound staging and inconsistent care documentation. The facility's wound care nurse lacked certification, and staff responsibilities were unclear.
The facility failed to develop accurate and comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as skin integrity, incontinence care, and the use of assistive devices. For instance, a resident at high risk for skin breakdown had a care plan indicating moderate risk, and another resident's care plan lacked specific interventions for incontinence. These oversights could result in inadequate care delivery.
The facility failed to provide competent wound care for residents, as evidenced by inaccurate assessments, improper documentation, and lack of certified wound care staff. Residents were found with untreated or improperly treated wounds, and staff were unfamiliar with equipment like Low Air Loss Mattresses. In-service training was insufficient, leading to inconsistent care and documentation.
A facility failed to notify a resident's family and physician about a significant change in the resident's condition, specifically a stage 4 sacral wound. Despite a family member being present and a skin assessment being documented, the family was unaware of the infected pressure ulcer until the resident was hospitalized. The facility's records did not reflect communication of the skin integrity change, and staff interviews revealed unfamiliarity with the resident's wound care.
The facility failed to properly label, date, and discard food items, and did not adhere to sanitization procedures for kitchen equipment. An opened container of thickened water was found beyond its use-by date, and a box of tea bags was undated. Additionally, a cook did not immerse equipment in sanitizing solution for the required time and used it before it was fully air-dried, risking contamination.
The facility failed to properly dispose of garbage and maintain sanitation in the dumpster area, affecting all 102 residents. Observations revealed dumpsters with broken or bent lids, not fully closed due to being full, and uncovered garbage bins. The Dietary Manager and Maintenance Staff acknowledged the need for closed dumpsters to prevent pests. Despite requests, no garbage disposal policy was provided, only a pest control policy mentioning trash removal.
The facility failed to transmit MDS records to the CMS system within the required timeframes for 10 residents. The delay was due to staffing issues, with the part-time MDS coordinator only available on weekends and working remotely on weekdays. The MDS Regional Consultant confirmed the late transmissions, which were documented in the facility's final validation report.
The facility failed to properly store and label medications, including unrefrigerated insulin, expired multivitamins, and unsecured controlled substances. Medication carts contained loose, unidentified tablets, and medication refrigerators were not maintained, with ice buildup and unlocked controlled medication storage. The facility's policies on medication storage were not adhered to.
A LTC facility failed to follow infection control policies, including a lack of PPE use for a resident on contact isolation, improper incontinence care by a CNA, and the use of a contaminated nasal cannula. These actions were against the facility's established guidelines, potentially compromising resident safety.
The facility failed to offer, educate, and document the benefits and risks of Influenza and Pneumococcal vaccines to four residents. The Director of Nursing/Infection Preventionist could not provide consent forms or documentation of education, and immunization records lacked evidence of vaccine administration. Interviews revealed residents were not informed about the vaccines, and facility policy requiring education and documentation was not followed.
The facility failed to offer, educate, and document COVID-19 vaccination for four residents. The DON/Infection Preventionist could not provide evidence of education or consent in the residents' records. Interviews revealed a lack of communication about the vaccine, with some residents expressing they were not informed or did not receive the vaccine despite being offered. The facility's policy required education and documentation, which was not followed.
A resident with cognitive and mobility impairments was found with their call light out of reach, contrary to their care plan and staff expectations. The resident was unaware of the call light's location, and staff confirmed it should be accessible. The facility's policy lacks specific guidance on call light placement.
A resident expressed a desire to be resuscitated (Full Code), but the facility failed to document a code status in the resident's admission record, order summary report, and care plan. A nurse was unsure of the resident's code status and needed to check computer records. The Director of Nursing confirmed the absence of a documented code status, despite facility policy requiring it to be part of the resident's plan of care.
The facility failed to provide timely incontinence care for two residents who required assistance with toileting, resulting in soiled briefs for extended periods. Additionally, a resident returning from the hospital did not receive personal hygiene assistance promptly, remaining on hospital sheets overnight. These deficiencies affected three residents reviewed for ADL care.
A facility failed to re-evaluate the necessity of a resident's enteral feeding, despite the resident consuming 50% or more of meals and expressing a desire to have the g-tube removed. The resident showed significant weight gain and improved oral intake, but the facility did not consistently document meal intakes or communicate the resident's nutritional improvement to the primary physician. This lack of communication prevented the physician from making an informed decision about the g-tube's removal.
The facility failed to provide proper respiratory care for two residents, resulting in deficiencies in oxygen therapy management. One resident's oxygen tubing was not dated as required, and another resident's nasal cannula was not in place despite the oxygen concentrator being on. Both residents had significant medical histories and required continuous oxygen therapy, which was not administered according to the physician's orders.
A resident with major depressive disorder did not receive their prescribed Wellbutrin SR consistently due to the facility's failure to reorder the medication in a timely manner. The MAR indicated multiple days when the medication was unavailable, and progress notes lacked explanations or physician notifications. Nursing staff were aware of the protocol to reorder medications when supplies were low, but it was not followed, resulting in missed doses.
A facility failed to maintain a medication error rate below 5%, with errors including a nurse not administering Aspirin to a resident and using incorrect measurement for MiraLax. Another nurse administered medications orally instead of via a gastrostomy tube as ordered. These actions violated the facility's medication administration policy.
A resident developed a severe pressure ulcer due to the facility's failure to assess and manage skin integrity. Despite being at risk, the resident's wound care was delayed, and preventive measures were not effectively implemented. The resident's condition worsened, leading to hospitalization and surgical intervention.
Failure to Reposition Dependent Resident at High Risk for Pressure Injuries
Penalty
Summary
The facility failed to ensure that a totally dependent resident with existing skin breakdown was repositioned every two hours as care planned and expected by facility policy. The resident, an older adult with hemiplegia and hemiparesis following cerebral infarction, vascular dementia, a stage 3 sacral pressure ulcer, frontotemporal neurocognitive disorder, and hypertensive heart disease, was observed on 3/23/26 at 3:26 pm lying in bed on his right side with the head of the bed elevated. At that time, his family member reported that he had been lying on his right side since around 10:00 am that morning and that she had been waiting for staff to help her turn him because he already had a pressure sore. The CNA assigned to the resident stated at 3:45 pm that she had been on duty since 7:00 am and believed the last time she repositioned the resident was at 9:00 am. She reported that staffing was reduced, with only three CNAs on the unit instead of the usual four, and that she could not reposition the resident by herself and could not always find someone to assist. She also stated she did not know the resident’s sister would help reposition him and acknowledged the resident should be repositioned every two hours and had a wound on his heel. The LPN assigned to the resident stated she was not sure when the resident was last turned and that the CNA was responsible for repositioning. The DON confirmed the resident had a left heel wound being monitored, that the resident could not turn himself, and that it was expected he be turned and repositioned every two hours. The resident’s care plan documented he was at high risk for skin breakdown, required total care and dependent assistance for mobility, and should be repositioned every two hours and as needed, consistent with the facility’s pressure injury prevention policy requiring repositioning of residents with or at risk of pressure injuries on an individualized schedule.
Delay in Incontinence Care and Transfer Assistance Leads to Resident Distress
Penalty
Summary
A resident who required staff assistance for activities of daily living (ADLs), including incontinence care and transfers, was left waiting for over an hour without timely help. The resident was observed sitting on the side of the bed with a walker in front, unable to reach the call light, which was wrapped around the bedside table behind him. Urine was present on the floor beneath the resident, with his foot in the puddle, and he reported waiting for assistance to be cleaned and transferred to a chair. The resident expressed feelings of humiliation and embarrassment due to the prolonged wait and lack of care. The resident's medical record indicated a need for assistance with personal care, muscle weakness, abnormal gait, unsteadiness, and a history of falls, but he was cognitively intact. Staff interviews revealed that the CNA assigned to the resident had a heavy workload and was unable to provide timely assistance due to staffing shortages and the need for two-person assistance for safe transfers. The CNA stated that only one nurse and one other CNA were working on the unit, making it difficult to provide prompt care. The Assistant DON confirmed that any staff member could assist residents and that waiting an hour for help was excessive. Facility policies required that residents unable to perform ADLs independently receive appropriate care and that call lights be within easy reach, both of which were not followed in this instance.
Failure to Provide Clean Linens for Resident Hygiene Needs
Penalty
Summary
The facility failed to provide clean bed and bath linens for residents requiring assistance with daily hygiene, bathing, or showers. Observations revealed that residents did not have access to clean towels or washcloths, with some staff resorting to using blankets for bed baths and to cover urine accidents. One resident was observed sitting on the side of the bed with a urine-like spot on the floor and on their foot, stating they had waited over an hour for assistance and did not have any clean towels or washcloths available. Another resident reported that the facility often ran out of towels, washcloths, and pillowcases, sometimes requiring them to use their own linens or take what was available from carts. Staff interviews confirmed frequent shortages of linens, particularly towels and washcloths, and described the need to use alternative items or retrieve linens from the laundry room themselves due to insufficient supply on the units. Further investigation in the laundry and linen storage areas showed a limited number of towels and washcloths available, with distribution records indicating that the amount of linen provided to each unit was less than the number of residents. The laundry aide reported being the only staff member until the afternoon, making it difficult to keep up with washing, sorting, folding, and distributing linens in a timely manner. The Assistant Director of Nursing stated that the amount of linen delivered was not enough to provide adequate care, and the Administrator was unaware of the limited stocking practices. Inventory records confirmed that the total number of towels in the facility was insufficient to provide even the minimum of two towels per resident. The residents affected included one individual with moderate cognitive impairment and multiple chronic conditions, including palliative care needs, and another with intact cognitive function but significant physical limitations following joint replacement surgery. Both required assistance with hygiene and daily living activities, as documented in their care plans. Facility policies and job descriptions outlined the expectation for providing a clean, safe, and homelike environment, including the provision of clean linens, but these standards were not met due to the ongoing linen shortages and inadequate staffing in the laundry department.
Failure to Provide Required RN Coverage and Supervision of IV Medication Administration
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least 8 consecutive hours daily, 7 days a week, as required by regulation. Review of staffing schedules and interviews with staff revealed that there were multiple days in May when no RN was present in the facility, and the nursing scheduler confirmed that some schedules were composed entirely of Licensed Practical Nurses (LPNs) without RN coverage. The Assistant Director of Nursing acknowledged that there were days without RN coverage and that the facility was not in compliance with the requirement for daily RN presence. A resident with a history of infection and inflammatory reaction due to an internal joint prosthesis was receiving intravenous antibiotics (Cefazolin) via a PICC line. Medication administration records showed that LPNs, rather than RNs, were administering these IV antibiotics. Staff interviews confirmed that LPNs were not certified to administer IV medications independently and that RNs had not supervised or monitored the administration of IV antibiotics by LPNs for this resident. The facility's own policies and job descriptions require RNs to supervise clinical care and ensure compliance with federal, state, and local regulations. Despite this, the facility's staffing records and staff statements indicated that there were days with no RN coverage, and LPNs were performing tasks outside their scope of practice without RN supervision. This deficiency had the potential to affect all residents in the facility, as confirmed by the census and the nature of the care being provided.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's food storage, labeling, temperature monitoring, and sanitation practices. During a kitchen tour, it was observed that refrigerators, freezers, and coolers lacked current temperature logs, with several missing entries on the previous month's logs. Most foods in cold storage were not labeled with open or expiration dates, and some potentially hazardous foods, such as tuna fish, slaw salad dressing, cottage cheese, and bacon, were found with past due expiration dates or no dates at all. Additionally, a box of bacon was found unsealed and open to air, and a container of tuna salad and a jar of slaw salad dressing were not properly dated. The dietary manager acknowledged these issues, stating that outdated perishable foods could cause illness. Further observations revealed that the facility did not maintain proper sanitizing water concentrations in dishwashing areas. Critical control point tests on sanitation buckets used for cleaning dishes and silverware showed results outside the required range, with one bucket testing at 300 ppm (above the 200 ppm standard) and another at 100 ppm (below the standard). Staff confirmed that improper sanitizing concentrations could result in unclean dishes and pose a risk to residents. Facility policies reviewed by surveyors required proper food labeling, storage, temperature monitoring, and sanitation, but these were not followed as observed during the survey.
Improper Garbage Disposal Leading to Pest Infestation and Odor
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not maintaining a closed lid on a garbage can stored near the dry storage room. On observation, the garbage can was found without a lid, emitting a foul odor, and attracting several small black insects flying around the opening. The Dietary Manager confirmed that this has been an ongoing issue, describing the area as 'fruit fly central,' and acknowledged the presence of a foul odor and insects. The facility's policy requires all waste destined for disposal to be placed in closable, leak-proof containers, but this was not followed. The census at the time documented 93 residents residing in the facility, all of whom were affected by this deficiency.
Incomplete Facility Assessment and Resource Planning
Penalty
Summary
The facility failed to complete a thorough and accurate facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment lacked input from residents, resident family members, and direct care staff. Additionally, it did not specify staffing needs by shift and unit, nor did it include a plan for staff recruitment and retention. There was also no contingency planning for events that could affect resident care but do not require activation of the emergency plan, such as nurse staffing shortages. Several required sections of the assessment, including those addressing medical practitioner recruitment, staff familiarity with standards of care, inventory management, health information technology, and infection prevention and control, were left blank or incomplete. The administrator confirmed that the assessment was completed only with input from select facility leadership and the governing body, without broader stakeholder involvement. The administrator also acknowledged the absence of a contingency staffing plan and recruitment/retention system in the assessment, and stated that certain sections were left blank because they were believed to be non-mandatory. The facility census at the time documented 93 residents who could potentially be affected by these deficiencies in the facility assessment process.
Failure to Implement Effective Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices as evidenced by multiple observed deficiencies. One resident with a feeding tube and wounds was not placed on Enhanced Barrier Precautions (EBP) as required, despite having physician orders and being listed as needing EBP. The absence of an EBP sign on the resident's door meant that staff were not alerted to use appropriate personal protective equipment (PPE), such as gowns and gloves, during high-contact care, increasing the risk of transmission of multi-drug resistant organisms (MDROs). Staff interviews confirmed that EBP signage is necessary for residents with wounds or indwelling devices, and its absence could result in staff not following required precautions. Hand hygiene practices were also found to be deficient. A certified nursing assistant was observed passing food trays to multiple residents without performing hand hygiene between residents, even after touching her face and handling items on the dietary cart. There were no hand sanitizer dispensers available in the hallway, on PPE carts, or at the nurse's station, and staff reported that hand hygiene supplies were often insufficient or inconveniently located. Staff interviews revealed that the lack of accessible hand hygiene products made it challenging to comply with hand hygiene protocols, and sometimes staff had to purchase their own supplies. Additionally, the facility failed to properly handle soiled linen. Observations showed that soiled linens were sometimes thrown down the laundry chute without being bagged, and soiled linen bags could break open, leaving contaminated items exposed in the laundry area. Facility policy requires all soiled linen to be bagged and contained before being placed in the chute, but staff acknowledged that this was not always followed. These failures in infection control practices were observed to have the potential to affect all residents on the affected unit and throughout the facility.
Failure to Maintain Clean and Safe Laundry Area Due to Inadequate Lint Trap Cleaning
Penalty
Summary
The facility failed to maintain a safe and clean environment by not thoroughly cleaning the lint screens in the laundry room dryers. During a tour of the laundry area, multiple dryers were observed with overfilled and bulging lint traps, as well as copious amounts of lint on the floor beneath the filter traps. One dryer, though out of order, also contained a full lint trap. The laundry aide confirmed that lint traps are supposed to be cleaned at scheduled times throughout the day but admitted that the cleaning had not been performed as required on the day of observation. The aide acknowledged the importance of cleaning lint traps for both effective drying and fire prevention. The Maintenance Director stated that laundry aides are responsible for cleaning the lint traps at specific times during their shifts and that training is provided on this task. The facility's job descriptions and maintenance policy require staff to maintain equipment and cleanliness in accordance with safety regulations. Despite these policies, the observed failure to clean lint traps as scheduled created an environment that was not adequately safe or clean for the residents, staff, and public, potentially affecting all 93 residents in the facility.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to eliminate black flying insects, specifically fruit flies, in the kitchen area. During observation, a garbage can near the dry storage room was found without a lid, emitting a foul odor, and attracting several small black insects. The Dietary Manager confirmed that the presence of fruit flies has been an ongoing issue and noted that the garbage can was filled with garbage and surrounded by black insects. Although pest control had treated the kitchen for fruit flies three weeks prior, the problem persisted. Interviews with facility staff revealed a lack of awareness and communication regarding the pest issue. The Administrator was not aware of the pest problem in the kitchen until it was reported by the Dietary Manager, and the Maintenance Director, who is responsible for pest control, stated that no one had informed him about fruit flies in the kitchen, though he had noticed them in the dish room. Review of pest control service inspection reports showed no documentation of treatment for fruit flies or similar pests on multiple preventive service dates. The facility's pest control policy requires an ongoing program to keep the building free of pests, but the observed and reported conditions indicate this was not effectively implemented.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its staff, as required. During the survey, the administrator was unable to produce any documentation showing that QAPI training had been conducted for staff in 2024 or 2025. The in-service binders provided did not contain any evidence of QAPI-related training, and both the administrator and nurse consultant confirmed that no such documentation existed. The nurse consultant and assistant director of nursing also searched the director of nursing's office for additional records but found none. Furthermore, there was no training schedule for required in-services, and the facility assessment did not identify a need for QAPI training. Interviews with facility leadership revealed that direct care staff were not trained on QAPI and would not know how to submit concerns directly to the QAPI committee, as the established process was to report issues to supervisors. The nurse consultant acknowledged that direct care staff should be involved in QAPI processes, as they are integral to identifying and driving needed changes. The lack of QAPI training documentation and absence of a training schedule affected all 93 residents in the facility, as staff were not adequately prepared to participate in or contribute to the facility's QAPI program.
Lack of Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to provide compliance and ethics training to its staff, as evidenced by the absence of documentation verifying such training. During the survey, the administrator was unable to produce any records of compliance or ethics in-services for staff in the provided in-service binders for 2024 and 2025. Further searches by facility leadership, including the nurse consultant and assistant director of nursing, did not yield any additional documentation. The administrator confirmed that there was no further documentation available regarding compliance or ethics training. Additionally, the facility assessment did not identify a need for compliance and ethics training, and the job description for certified nursing assistants only referenced involvement in yearly mandated education without specifying compliance or ethics. Although the facility has a compliance and ethics program and a hotline for reporting concerns, there was no evidence that staff had received training on these topics. This deficiency has the potential to affect all 93 residents residing in the facility.
Failure to Conduct and Document Resident and Family Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted and that residents or their family members participated in the development of comprehensive care plans. Four residents were affected, including individuals with moderate cognitive impairment and one resident on hospice care with impaired communication. Interviews revealed that these residents were not familiar with their care plans, had not attended care plan meetings, and had not received copies of their care plans. Family members also could not recall recent care plan meetings for their loved ones. Record reviews confirmed a lack of documentation regarding care plan meetings or resident/family participation for these individuals, even after significant events such as readmission. Staff interviews indicated that care plan meetings were supposed to occur quarterly and with significant changes, but documentation supporting resident or family participation was lacking. The MDS Coordinator confirmed that only nursing and social services typically conducted these meetings, with no involvement from dietary or certified nursing assistants. Facility policy encourages resident and family participation in care planning, but there was no evidence that this was consistently implemented for the affected residents.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents requiring oxygen therapy. For one resident with COPD and respiratory failure, the nasal cannula was connected to a humidifier bottle that was not properly attached, resulting in no oxygen being delivered. This was confirmed by the absence of bubbles in the humidifier bottle, and the issue was only corrected after multiple attempts by an LPN. The resident had a physician's order for continuous oxygen at 3 liters per minute, and facility policy required that the humidifier bottle be securely fastened and bubbling to ensure oxygen delivery. Another resident with chronic respiratory conditions was observed receiving oxygen via nasal cannula at 2 liters per minute, but the oxygen tubing was not labeled with the date it was last changed. Facility policy and the resident's order required weekly changes of oxygen tubing, with labeling and dating to ensure proper infection control. The resident was unable to be interviewed due to severely impaired cognition, and the Assistant Director of Nursing confirmed the expectation for weekly tubing changes and proper labeling. A third resident with multiple respiratory and cardiac diagnoses was observed receiving oxygen at a flow rate of 4 liters per minute, despite an active physician's order for 3 liters per minute continuously. The LPN on duty verified the discrepancy and acknowledged the need to follow the physician's order to prevent complications. The ADON stated that nurses are responsible for ensuring oxygen is set according to orders during medication passes and pulse oximetry checks.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, specifically impacting one resident who required assistance with activities of daily living. On one occasion, a resident was observed sitting on the side of the bed with a walker in front of him, his call light out of reach, and his foot in a puddle of urine. The resident reported waiting for over an hour for help to transfer to a chair and to be cleaned up. Staff confirmed that they were unable to assist the resident promptly due to staffing shortages and the need for two people to safely transfer the resident, resulting in prolonged waiting times. Interviews with staff revealed that the unit was frequently staffed with only one nurse and two CNAs for 24 residents, despite the need for more personnel to provide adequate care, especially for residents requiring two-person assistance. Staff members expressed concerns about heavy workloads and the inability to provide timely care, with one CNA stating that they would not risk moving a resident alone due to fall risk. The Assistant DON acknowledged that the unit should have two nurses and two CNAs on the AM shift, but coverage was often insufficient due to call-offs and difficulty securing agency staff. A review of staffing schedules for the month showed that the unit was short one nurse on 28 out of 31 days for the AM shift. Facility policies require sufficient staffing to meet residents' needs and ensure call lights are within reach, but these standards were not consistently met. The resident involved had diagnoses including muscle weakness, unsteadiness, and a history of falls, and was cognitively intact, further highlighting the impact of inadequate staffing on resident care and dignity.
Deficiencies in Controlled Medication Handling and Medication Storage
Penalty
Summary
The facility failed to ensure proper handling and documentation of controlled medications, as well as appropriate storage and monitoring of medication refrigerators. During a survey, it was observed that incoming and outgoing nurses did not consistently count controlled medications during shift changes, and there were missing signatures on the narcotic accountability sheets. In one instance, a nurse administered a controlled medication to a resident but did not immediately document the administration, resulting in a discrepancy between the number of capsules recorded and the actual count in the medication dispensing card. Another nurse was unaware of the proper procedures for repackaging medications and could not identify who had repackaged a resident's medication into pill sleeves, which was not in accordance with facility policy. Additionally, the survey revealed that one of the medication refrigerators lacked a temperature log sheet, and the other had an outdated log, contrary to facility policy requiring daily temperature monitoring to ensure safe medication storage. The absence of current temperature logs was acknowledged by staff, who stated that this could result in medications being stored at unsafe temperatures. Furthermore, personal food items belonging to staff were found stored in the medication refrigerator, which is prohibited by facility policy due to the risk of contamination and potential harm to residents' medications. The deficiencies affected two residents who were prescribed controlled medications for pain and seizure management. The facility's own policies require accurate documentation, proper storage, and regular monitoring of controlled substances and medication storage areas, but these procedures were not consistently followed as evidenced by the surveyor's observations and staff interviews.
Failure to Maintain Resident Dignity by Not Covering Catheter Drainage Bags
Penalty
Summary
Multiple residents with indwelling urinary catheters were observed without privacy bags covering their catheter drainage bags. The drainage bags were hung on the sides of the beds and were visible from the hallway when the doors were open. Specifically, three residents were noted to have their catheter bags uncovered and in plain view during observations conducted on the same day. One resident reported never having a privacy bag for their catheter during their stay at the facility. Staff interviews confirmed that facility policy requires catheter bags to be covered for resident dignity and privacy. Both a Licensed Practical Nurse and the Assistant Director of Nursing acknowledged that the lack of privacy bags for catheter drainage bags does not protect resident privacy and is not in accordance with facility policy. Record review showed that one resident was cognitively intact and had active orders for indwelling catheter care every shift. Facility policies reviewed emphasized the importance of maintaining resident dignity, including the expectation that urinary catheter bags be kept covered.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents as required by their care plans and facility policy. Observations revealed that one resident was unable to locate the call light, which was found under the bed, and the resident was unaware of its location. This resident had a history of repeated falls, vascular dementia, and mobility impairments, and was care planned to have the call light within reach due to high fall risk. Another resident was observed with the call light on the floor, and a staff member acknowledged that the resident did not use the call light, so the door was kept open instead. A third resident was found sitting on the side of the bed with the call light wrapped around a bedside table out of reach, and was left waiting in urine for over an hour for assistance, expressing embarrassment and distress. Staff interviews confirmed that call lights were not always kept within reach, and that staffing shortages contributed to delays in providing assistance. Facility policies reviewed stated that call lights should be within easy reach of residents when in bed or confined to a chair, and that residents unable to perform activities of daily living independently should receive necessary assistance. Staff acknowledged the importance of call light accessibility for timely response to resident needs, including pain management and toileting. The failure to keep call lights within reach was observed to directly impact residents' ability to request help, resulting in delays in care and unmet needs.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) assessment for one resident within the required timeframe. The assessment, with a reference date of 4/7/2025, was completed and signed on 4/16/2025, but there was no documentation in the resident's electronic health record indicating that it had been transmitted to CMS as required. A review of the validation report confirmed that the assessment was not transmitted until 6/3/2025, well beyond the mandated submission period. During an interview, the MDS Coordinator acknowledged the oversight, stating that the assessment was missed and only submitted after the survey team requested it. Facility policy requires that all resident assessments be conducted and submitted in accordance with federal and state timeframes.
Failure to Follow Physician Orders for Weight Monitoring in Heart Failure Patient
Penalty
Summary
The facility failed to follow physician orders for obtaining weights for a resident with a history of hypertensive heart disease, heart failure, and documented weight loss. The resident's care plan identified the need for close monitoring due to the use of diuretic medications, which can cause weight fluctuations. The physician order specified that the resident's weight should be obtained every morning, with instructions to notify the physician if there was a weight gain of 2 pounds in one day or 5 pounds in one week. However, the order also included a frequency of once daily every Tuesday and Thursday, leading to confusion among staff. A review of the resident's weight records for May showed that weights were only documented on two occasions, with a 16-day gap between entries. The Assistant Director of Nursing confirmed that weights were not obtained as ordered and acknowledged the importance of daily weights for monitoring heart failure exacerbations. The facility's policy required weights to be recorded in both the unit's weight record chart and the resident's medical record, but this was not consistently done for the resident in question.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's pressure ulcer prevention and care practices. One resident was seen sitting in a wheelchair for an extended period without a pressure-relieving cushion, despite having a care plan indicating actual skin integrity impairment and an MDS assessment identifying risk for pressure ulcers. The registered nurse confirmed that a cushion was needed to prevent pressure ulcers, but the resident was left without one during the observations. Two other residents were found lying on low air loss mattresses that were not set up according to manufacturer instructions or facility policy. One resident's mattress was set at a weight significantly higher than the resident's actual weight, which staff acknowledged would make the mattress too firm and ineffective for pressure redistribution. Both residents had multiple layers, including folded blankets and extra sheets, placed between them and the mattress, contrary to both the facility's policy and the mattress manufacturer's guidelines, which specify only a thin sheet should be used. The records for these residents documented significant risk factors for pressure ulcers, including diagnoses such as vascular dementia, severe protein-calorie malnutrition, hemiplegia, and impaired mobility. Care plans and physician orders specified the use of pressure-reducing devices and preventive measures, but these were not properly implemented. Staff interviews confirmed that the observed practices did not align with facility policy or clinical guidelines for pressure ulcer prevention.
Failure to Label and Replace Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of piston syringes and distilled water containers used for enteral feeding and flushing in multiple residents with gastrostomy tubes. Surveyors observed that piston syringes at the bedsides of several residents were not labeled with the date they were changed, and containers of distilled water used for flushing G-tubes were not marked with the date they were opened. Staff interviews confirmed that the expectation was for these items to be labeled and changed daily to maintain infection control, but this was not consistently done. For one resident with a G-tube and severe cognitive impairment, a piston syringe container was found unlabeled, and the distilled water used for flushing the tube was also not dated. The care plan and facility policy required daily changes and labeling of these items, but staff acknowledged that this was not always followed. Another resident, who was alert but unable to communicate, also had an unlabeled feeding tube piston syringe at the bedside. Staff stated that syringes should be labeled and changed regularly to prevent bacterial growth, but this was not observed in practice. A third resident's room was found to have a tube feeding syringe and an enteral tube feeding adaptor placed loosely on the bedside table, both not contained or labeled, and an open gallon of distilled water without an open date. Staff interviews reiterated that all such items should be labeled and changed daily, and that adaptors should be kept with the patient and not left out. The lack of labeling and proper containment of these items was confirmed by multiple staff members, including the DON and ADON, as not meeting facility expectations for infection control.
Missed IV Antibiotic Dose Results in Significant Medication Error
Penalty
Summary
A resident with a medical history including infection and inflammatory reaction due to an internal joint prosthesis was prescribed intravenous Cefazolin 2g every 8 hours via a PICC line for prophylaxis. On observation, a full bag of IV Cefazolin was found hanging in the resident's room, not connected, and the resident was unsure if the morning dose had been administered. The resident reported not refusing the medication, and the IV access site was present and intact. Review of the physician's orders confirmed the requirement for timely administration of the antibiotic, and facility policy required medications to be administered as prescribed and in a timely manner. A Licensed Practical Nurse (LPN) confirmed that the 6:00am dose of Cefazolin had not been given and that there was no documentation in the electronic medical record explaining the missed dose. The LPN also stated that the physician should be notified of the missed dose. The infection preventionist later confirmed the resident did not refuse the medication and was unable to reach the nurse responsible for the missed administration. Facility policy emphasized the importance of timely medication administration, but this was not followed, resulting in a significant medication error for the resident.
Failure to Provide Communication Training for Staff
Penalty
Summary
The facility failed to provide communication training to its staff, as evidenced by the lack of documentation of such training in the in-service binders for 2024 and 2025. This deficiency was identified during a survey when the surveyor requested records of staff training on communication and was informed by the administrator that all in-service records would be in the provided binders. Upon review, no evidence of communication training was found. Further, the nurse consultant and assistant director of nursing confirmed that no additional documentation existed and that there was no established training schedule for required in-services, including communication. This deficiency directly affected a resident whose primary language is Chinese and who requires an interpreter for communication. The resident's family member reported that staff had difficulty communicating with the resident due to the language barrier, necessitating the family member's daily presence to interpret and ensure appropriate care. The facility's assessment did not identify a need for communication training, and the job description for certified nursing assistants only referenced involvement in mandated education without specifying communication training.
Mail Opened Without Resident Permission
Penalty
Summary
A deficiency occurred when the Director of Nursing (DON) opened a resident's personal mail without the resident's permission. The resident, a sixty-six-year-old man with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, sleep apnea, type II diabetes, major depression, anxiety disorder, and hypertension, was alert and oriented and able to make his needs known. The DON opened a package addressed to the resident after being informed by the receptionist that it likely contained medications. The DON found several bottles of pills inside, placed them in the medication cart, and later informed the resident about the package and the handling of his medications. The resident reported to surveyors that his mail was opened without his consent and expressed concern about not knowing what was sent or how many pills were received. The resident's family member confirmed that the resident had communicated this concern. The facility's policy, as well as the Ombudsman Program guidelines, clearly state that mail must be delivered promptly and not opened without the resident's permission. Both the DON and the facility administrator acknowledged that the mail should not have been opened without the resident's consent or presence.
Failure to Respond Timely to Resident's Call Light
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, affecting one out of three residents reviewed for call light response. On one occasion, the resident, who was dependent on care, experienced chest pain and activated the call device. After waiting for 10 minutes without a response, the resident called the Director of Nursing (DON) on their cell phone, who then sent a nurse to assist. The resident was subsequently sent to the hospital and treated for a heart attack. A call device response check revealed that it took 11 minutes for a staff member to respond to the resident's call light. In another instance, the resident was observed attempting to transfer from a wheelchair to the toilet without assistance. The resident had asked for help from two staff members, but was informed that their CNA was on break. After waiting 20-30 minutes, the resident attempted the transfer independently. When the surveyor instructed the resident to activate the bathroom call light, it was found that the call device was not functioning properly, as it did not signal in the hallway. A staff member confirmed that the call device was not activated and only the call box was functioning. The Director of Nursing denied knowledge of any complaints regarding the resident's call light not being answered or functioning properly. The DON stated that any staff member could respond to a call light and that nursing staff should check call lights daily to ensure they are functioning. The resident's medical history includes Parkinson's disease, spinal stenosis, osteoporosis, and chronic kidney disease, and they require substantial assistance with toileting. The facility's guidelines emphasize the importance of ensuring call lights are plugged in and functioning, and defective call lights should be reported promptly.
Failure to Provide Functioning Call Device for Resident
Penalty
Summary
The facility failed to provide a functioning call device for a dependent resident, identified as R3, who requires assistance from staff. On the specified date, R3 was observed attempting to transfer from a wheelchair to the toilet without assistance, after waiting 20-30 minutes for help. R3 had previously requested assistance from two LPNs, who informed R3 that the assigned CNA was on break and would be notified upon return. When instructed by the surveyor to activate the bathroom call light device, it was observed that although the device in the bathroom was flashing, the call device outside R3's room was not functioning, failing to signal for help in the hallway. Further investigation revealed that the call device was not alarming at the nurses' station either. The Maintenance Director, V23, assessed the situation and suggested that the issue might be due to a bulb needing replacement. V23 admitted to not performing regular call device checks, relying on staff to report malfunctions. The Director of Nursing, V2, explained that it is the nursing staff's responsibility to ensure call lights are functioning and to notify maintenance if they are not. R3's medical history includes Parkinson's disease, spinal stenosis, osteoporosis, and other conditions, requiring substantial maximal assistance with toileting. The facility's procedures emphasize the importance of functioning call lights for timely responses to residents' needs, yet this protocol was not followed, leading to the deficiency.
Resident Falls Due to Faulty Overbed Table
Penalty
Summary
The facility failed to maintain an overbed table in good working condition, leading to a fall incident involving a resident. The resident, identified as R2, was sitting in the hallway by the nurses' station and leaning on the overbed table when the tabletop detached from the base, causing her to fall and hit her right side on the floor. The incident was witnessed by a CNA and a physical therapy assistant, and it was noted that the tabletop was no longer connected to the base after the fall. Interviews with facility staff revealed that there was no preventative maintenance conducted on the overbed tables prior to the incident. The Maintenance Director admitted that the tables were not checked unless issues were reported, and the tables were not designed to support weight beyond holding food. The lack of regular maintenance and the improper use of the overbed table contributed to the accident, as the screws attaching the tabletop to the base were found to be detached.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to significant deterioration in their conditions. For one resident, the facility did not follow its own policies and procedures, resulting in a stage 4 infected sacral wound that required surgical intervention. The resident was dependent on staff for repositioning and hygiene, yet the facility failed to conduct regular low air loss mattress checks, did not administer prescribed treatments consistently, and did not document wound care properly. The resident's wound care was neglected for five consecutive days, and the wound progressed to osteomyelitis, a severe bone infection. Another resident, who was also at high risk for skin integrity impairment, experienced a decline in their sacral pressure ulcer from stage 3 to stage 4. The facility did not ensure that the low air loss mattress was set correctly, and multiple layers of linen were placed between the resident and the mattress, rendering it ineffective. The facility also failed to document turning and repositioning every two hours as required, and wound care was inconsistently documented, with several blank entries noted in the treatment administration record. Additional deficiencies were noted for two other residents, including incorrect staging of wounds, failure to document wound care, and improper use of low air loss mattresses. One resident's wound was back-staged from stage 4 to stage 3, contrary to guidelines, and another resident's wound assessments contained conflicting information. The facility's wound care nurse lacked proper certification, and there was a lack of clarity and consistency in wound care responsibilities among staff, contributing to the inadequate care provided.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflect the needs of residents, as evidenced by deficiencies found in the care plans of four residents. Resident 1, who is bedridden and at high risk for skin integrity impairment due to obesity and muscle weakness, had a care plan that inaccurately stated a moderate risk for skin breakdown and excluded necessary interventions such as mechanical lift transfer. The Assistant Director of Nursing and MDS Coordinator acknowledged the discrepancies, noting that the care plan did not align with the resident's actual needs and risk assessments. Resident 2, who has dementia and muscle weakness, was found to have a care plan that did not include specific interventions for incontinence care, despite being dependent on staff for toileting hygiene. The MDS Coordinator confirmed that the care plan lacked a separate section for bowel incontinence, which was instead incorporated into the pressure ulcer risk plan. This oversight could lead to confusion among staff regarding the resident's specific care needs. Resident 3, diagnosed with Parkinson's disease and reduced mobility, also had a care plan that omitted incontinence care and toileting needs. The MDS Coordinator admitted that these interventions were not separately documented, potentially causing staff to overlook essential care requirements. Additionally, Resident 4, who was admitted with a stage 4 sacral pressure ulcer, did not have the use of a low air loss mattress documented in their care plan, despite its implementation. The facility's care plan policy mandates individualized plans within 14 days of admission, but these deficiencies indicate a failure to adhere to this standard.
Deficiencies in Wound Care and Staff Competency
Penalty
Summary
The facility failed to ensure that competent nursing staff were available to meet the needs of residents requiring wound care. This deficiency was evident in the care of four residents, where the facility did not have a certified wound care nurse for over a year, and the wound care assessments and treatments were not conducted accurately or documented properly. For instance, one resident was transferred to the hospital with a large sacral decubitus ulcer, which was not accurately assessed or treated at the facility. The wound care nurse responsible for this resident was not certified, and the treatment administration was not documented on the Treatment Administration Record (TAR). Another resident was found lying on a Low Air Loss Mattress (LALM) with multiple layers of linen beneath them, which rendered the mattress ineffective. The nursing staff were not familiar with the LALM settings, and the required checks and repositioning were not documented consistently. The facility's in-service training for LALM use was insufficient, as only a small fraction of the staff had attended the training sessions, leaving many staff members unaware of the proper procedures. Additionally, the facility's documentation and assessment of wounds were inconsistent and inaccurate. For example, one resident's initial wound assessment described a stage 4 sacral wound, but subsequent assessments incorrectly downgraded the wound to stage 3, contrary to established guidelines. Another resident's wound assessments were inconsistent, with discrepancies in the location and severity of the wounds. The facility's policies and procedures for wound management were not followed, leading to inadequate care and documentation for residents with pressure ulcers.
Failure to Notify Family and Physician of Resident's Condition Change
Penalty
Summary
The facility failed to adhere to its policy of promptly notifying the resident, their physician, and family members of significant changes in the resident's condition. This deficiency was identified in the case of a resident with a stage 4 sacral wound. Despite the presence of a family member at the bedside and the documentation of a skin assessment, the family was not informed about the infected pressure ulcer. The resident was later sent to the hospital, where the pressure ulcer was identified by hospital staff, indicating a lapse in communication from the facility. The facility's records show that the resident's medical doctor was informed of the resident's lethargy and altered mental status, but the change in skin integrity was not communicated. The hospital's records confirmed the presence of a large sacral decubitus ulcer and subsequent osteomyelitis. Interviews with facility staff revealed a lack of familiarity with the resident's wound care, further highlighting the communication breakdown and failure to follow the facility's notification policy.
Deficiencies in Food Handling and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items, as well as adequate sanitization and drying of kitchen equipment. During a kitchen tour, a surveyor observed an opened container of thickened water in the fridge with a date indicating it had been opened beyond the allowable seven days. The Dietary Manager acknowledged that the thickened water should have been discarded to prevent potential contamination or spoilage. Additionally, a box of tea bags was found opened without a date label, which is against the facility's policy that requires opened food items to be dated for proper tracking and disposal. Furthermore, the facility did not adhere to the required sanitization procedures for kitchen equipment. A cook was observed immersing blender components in a sanitizing solution for less than the required 60 seconds and using them before they were fully air-dried, with water still dripping from the equipment. The Dietary Manager confirmed that the facility uses a Quaternary solution for sanitization, which requires a full minute of immersion to effectively kill bacteria. The failure to properly sanitize and dry equipment could lead to moisture growth and potential contamination, affecting the quality and safety of food served to residents.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to properly dispose of garbage and maintain a sanitary condition in the dumpster area, which could potentially affect all 102 residents. During an inspection, the surveyor observed that the dumpster containing recycled items was not closed, with its lid broken or bent. Another dumpster with trash had a lid that was not fully closed due to being full of waste. Additionally, broken furniture and equipment were found around the dumpster area, and garbage bins with waste inside were not covered. The Dietary Manager acknowledged that the dumpsters should be completely closed to prevent flies and insects. The Maintenance Staff confirmed that the dumpster lid was bent and did not close completely, and another dumpster was not fully closed because it was full of garbage. The Director of Maintenance, who oversees waste management, stated that dumpsters should be completely closed to prevent rodents and insects. Despite multiple requests, the facility could not provide a policy for garbage disposal or dumpster management, only a pest control policy that mentioned garbage and trash should not accumulate and should be removed per policy.
Failure to Transmit MDS Records Timely
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) records to the CMS system within the required regulatory timeframes for 10 residents. The MDS Regional Consultant, who was temporarily covering the facility due to the absence of a full-time MDS coordinator, acknowledged that the MDS assessments were completed but not transmitted within the 14-day period as required by CMS guidelines. The delay in transmission was attributed to the current staffing situation, where the part-time MDS coordinator was only available on weekends and worked remotely during weekdays. The surveyor reviewed the MDS records for the 10 residents and found that all transmissions were late, with the final validation report confirming the late submissions. The report highlighted that the transmission dates exceeded the 14-day period from the completion date for each resident's assessment. This deficiency was documented in the facility's final validation report, which noted that the records were submitted late, impacting the facility's compliance with the CMS-specified Resident Assessment Instrument process.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, as observed during a survey. In one instance, an unopened vial of Insulin Aspart was found unrefrigerated in a medication cart, contrary to the label instructions to refrigerate until opened. Additionally, a bottle of multivitamins with an expiration date of March 2024 was still in use, despite being opened in May 2024. Loose tablets were found in medication carts, and the nurses were unable to identify them. The Director of Nursing acknowledged that narcotics and controlled medications should be double-locked, and insulin should be refrigerated if unopened. Further observations revealed that medication refrigerators were not properly maintained, with ice buildup noted in one refrigerator, and the responsible party for defrosting was unknown. In another instance, controlled medications were not double-locked as required, with a lockable box inside a refrigerator found unlocked, allowing easy access to the medications. The facility's policies on medication storage and controlled medication storage were not followed, leading to these deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies in several instances, leading to deficiencies in care. In one case, a resident on contact isolation for Extended Spectrum Beta-Lactamase (ESBL) was visited by her daughter, who was not informed of the need for personal protective equipment (PPE). The daughter was observed hugging the resident without wearing any PPE, contrary to the facility's policy that requires gowns and gloves for anyone interacting with residents on contact isolation. In another instance, an agency CNA failed to follow standard precautions during incontinence care for two residents. The CNA used the same washcloth to clean both the genitalia and buttocks of the residents and did not change gloves or perform hand hygiene before and after the procedure. Additionally, the CNA did not use a washbasin, soap, or water, and failed to dry the residents' skin, which is against the facility's policy for perineal care. A further deficiency was noted when a CNA placed a nasal cannula that had fallen on the floor back into a resident's nostrils without sanitizing or replacing it. This action was against the facility's infection prevention policy, which requires replacing contaminated equipment to prevent infection. The CNA acknowledged the mistake, and the Assistant Director of Nursing confirmed that such actions could lead to respiratory infections.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to offer, educate, and document the benefits and risks of Influenza and Pneumococcal vaccines to four residents. Upon review of the residents' vaccination records, it was found that these residents did not receive the influenza and pneumococcal vaccines. The Director of Nursing/Infection Preventionist (V2) was unable to provide any consent forms or documentation that the residents or their representatives were educated about the vaccines or the reasons for refusal. The immunization records did not document any administration of the vaccines, and there was no evidence of education provided to the residents. Interviews with the residents revealed that they were not informed about the vaccines. One resident expressed willingness to receive the vaccines but stated that no one explained them or administered them. Another resident, with impaired cognition, did not respond during the interview, and a BIMS score indicated cognitive impairment. The facility's policy requires that each resident or their representative receive education regarding the benefits and potential side effects of the vaccines, and that consent and education be documented in the resident's medical record. However, this procedure was not followed, leading to the deficiency.
Failure to Educate and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to offer, educate, and document the benefits and risks of the COVID-19 vaccines to four residents (R80, R401, R403, and R404) out of five reviewed for vaccinations. The surveyor's investigation revealed that these residents did not receive any COVID-19 vaccine, and there was no documentation of education or consent forms in their records. The Director of Nursing/Infection Preventionist (V2) was unable to provide any evidence of education or consent, either in the electronic health records or in the physical charts of the residents. Despite a binder being presented that supposedly contained consent forms and education records, the forms for these residents were not found. Interviews with the residents indicated a lack of communication and education regarding the COVID-19 vaccine. R404 and R401 were alert and able to express their thoughts, with R401 stating that he was offered the vaccine but never received it, and no one explained the vaccine to him. R403 and R80 had impaired cognition, with R403 not responding during the interview and R80 rarely or never understood, as indicated by their BIMS scores. The facility's COVID-19 Vaccination Policy required that all residents be educated and offered the vaccine, with documentation of education and consent or declination, which was not adhered to in these cases.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, identified as R94, is an elderly individual with diagnoses including encephalopathy, abnormalities of gait and mobility, cognitive communication deficit, and muscle weakness. R94's medical records indicate a moderately impaired mental status with a BIMS score of 12. During an observation, R94 was found sitting in a chair with the call light hanging over the side of the nightstand, out of reach. R94 was unaware of the call light's location. Interviews with a Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that call lights should be within a resident's reach. R94's care plan, which addresses potential fall risks and usual function, includes interventions to keep the call light within reach. However, the facility's call light policy does not specify the location of the call light in relation to the resident.
Failure to Document Code Status for Resident
Penalty
Summary
The facility failed to have an order for a code status for one resident, identified as R153, out of a total sample of 24 residents reviewed for advanced directives. On July 16, 2024, R153 expressed a desire to be resuscitated (Full Code) in the event of a change in condition. However, the resident's admission record, order summary report, and care plan did not document a code status. A nurse, identified as V8, indicated that R153 was Full Code if there were no Do Not Resuscitate (DNR) papers in the chart, but was unsure and needed to check the computer records. The Director of Nursing, identified as V3, stated that staff assess a resident's code status upon admission and consult with the resident or their representative if the resident is not decisional. Despite this procedure, R153's profile in the electronic medical records did not list a code status. The facility's policy and procedure on advance directives, dated January 15, 2013, states that the resident's choice of advance directive should be developed into their plan of care, which was not done in this case.
Failure to Provide Timely Incontinence and Hygiene Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, R10 and R50, who required assistance with toileting. R10, who was admitted with multiple diagnoses including chronic heart failure and diabetes, was observed with a heavily soiled incontinence brief at 12:02 pm, despite having been last changed at 8 am. R10 communicated that she had been calling for assistance but was not attended to. Similarly, R50, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was found with a soiled brief and a strong odor of urine at 12:10 pm, having also been last changed at 8 am. The facility's policy requires incontinence care to be provided at least every two hours to prevent skin breakdown, which was not adhered to in these cases. Additionally, the facility failed to provide personal hygiene assistance for R51 after returning from the hospital. R51, who was dependent on staff for personal hygiene and dressing, returned to the facility and was found by a family member still on hospital sheets and in a hospital gown the following morning. The family member reported multiple attempts to contact the facility the previous night without success. A CNA confirmed that R51 had not been changed or settled into bed until the morning after returning from the hospital. The facility's policy requires staff to introduce themselves, orient the resident to their room, and ensure their comfort within 10-15 minutes of admission, which was not followed in this instance. These deficiencies affected three residents in a sample of 24 reviewed for activities of daily living care. The facility's policies on incontinence care and resident rights emphasize the importance of timely care to prevent skin breakdown and ensure a dignified existence, which were not upheld in these cases.
Failure to Re-evaluate Necessity of Enteral Feeding
Penalty
Summary
The facility failed to re-evaluate the necessity of a resident's enteral feeding, despite evidence suggesting it may no longer be needed. The resident, identified as R83, had been receiving enteral feeding via a gastrostomy tube (g-tube) since June 2024, despite consuming 50% or more of meals and expressing a desire to have the g-tube removed. Observations and interviews revealed that R83 was eating well, with a significant weight gain of 7.6% over the last three months, and had been consuming 76-100% of meals when charted. However, the facility did not consistently document meal intakes, and the comprehensive care plan did not include goals for removing the g-tube. The facility's failure to communicate R83's nutritional improvement to the primary physician, V19, further contributed to the deficiency. V19 was not informed of R83's weight gain or improved oral intake, which would have prompted a calorie count to evaluate the need for the g-tube. The facility's Nutritional Intervention Procedure requires routine evaluation and documentation of resident food and beverage consumption, which was not adequately followed in this case. As a result, the resident continued to receive unnecessary enteral feeding, and the physician was not provided with the information needed to make an informed decision about the g-tube's removal.
Deficiencies in Oxygen Therapy Management for Two Residents
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen therapy management. For one resident, the oxygen tubing was observed without a date, contrary to the physician's order that required weekly changes and labeling. The resident was receiving oxygen at 3 liters per minute, and the tubing was not dated, which was confirmed by a registered nurse. The resident's medical history included end-stage heart failure, chronic obstructive pulmonary disease, and other significant conditions, and the resident required continuous oxygen therapy to maintain saturation levels above 90%. For another resident, the oxygen concentrator was on, but the nasal cannula was not in place, and the oxygen tubing was found at the bedside. The assigned nurse was unaware of the continuous oxygen order, which required the resident to use oxygen at 2 liters per minute continuously. This resident had a medical history of lumbar radiculopathy, osteoarthritis, and other conditions, with moderately impaired cognition. The facility's policy required adherence to medical orders for oxygen therapy, including the proper placement and use of the nasal cannula.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received their prescribed medication, Wellbutrin SR, as ordered. The resident, who has a diagnosis of major depressive disorder, reported that the facility did not consistently provide the medication, with specific instances of non-administration occurring over several days in May and June 2024. The Medication Administration Record (MAR) for these months documented that the medication was not available on multiple occasions, and progress notes indicated that the facility was waiting for pharmacy delivery. However, there were no progress notes explaining why the pharmacy had not delivered the medication or indicating that the physician had been notified of the issue. Interviews with nursing staff revealed that there was a protocol in place for reordering medications, which involved ordering a refill when the medication blister pack reached a designated blue area, indicating low supply. Despite this protocol, the medication was not reordered in time, leading to the resident missing doses. The Director of Nursing confirmed that nurses were instructed to reorder medications once they reached the blue portion of the blister pack. The facility's policy stated that residents should receive their medications on a timely basis, but this was not adhered to in the case of this resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by four medication errors out of 37 opportunities, resulting in a 10.81% error rate. One incident involved a nurse, V7, who prepared medications for a resident, R9, but failed to administer Aspirin 81 mg as ordered. The nurse charted the administration of Aspirin, although the surveyor did not observe it being prepared or given. Additionally, the nurse used a plastic spoon instead of the designated bottle cap to measure MiraLax, which is not in accordance with the facility's policy or the medication's instructions. Another incident involved a nurse, V15, who prepared medications for a resident, R83, and administered Thiamine Hydrochloride and Metformin Hydrochloride orally, despite the order specifying administration via a gastrostomy tube. The Director of Nursing, V3, confirmed that the facility's policy requires medications to be administered by the route ordered by the physician. These actions demonstrate a failure to adhere to the five rights of medication administration, which include the right patient, time, medication, route, and dose.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and manage the skin integrity of a resident, leading to the development of a severe pressure ulcer. The resident, who had no skin issues upon admission, was at risk for altered skin integrity due to incontinence and decreased mobility. Despite this, the facility's Minimum Data Set (MDS) initially documented that the resident was not at risk for developing pressure injuries. The resident was admitted to the hospital with an unstageable wound on the sacrum, which later required surgical intervention. Interviews and record reviews revealed that the facility did not implement timely wound care or preventive measures. The Assistant Director of Nursing (ADON) was unaware of the resident's wound, and wound care orders were delayed. The resident was incontinent and unable to call for help, yet the facility's protocol for repositioning and changing every two hours was not effectively followed. The resident's family reported noticing a smell of urine and feces, and the resident developed a rash and wound that worsened significantly. The facility's policies on pressure ulcer treatment and prevention were not adequately executed. The resident's Treatment Administration Record (TAR) showed no treatments for the wounds on specific dates, and there was a lack of communication and documentation regarding wound care orders. The facility's failure to adhere to its own protocols and the lack of timely intervention contributed to the resident's condition worsening, resulting in hospitalization and further complications.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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